Senior Director of Claims and Eligibility Operations - REMOTE

Senior Director of Claims and Eligibility Operations - REMOTE

Role And Responsibilities

The Senior Director of Claims and Eligibility Operations is responsible for the strategic leadership and operational oversight of two critical and interdependent functions within Liviniti's Operations organization: Claims Adjudication and Eligibility Operations. This is a senior leadership role that carries accountability for the accuracy, integrity, and performance of both verticals, and serves as the primary operational and technical authority bridging platform capability with day-to-day execution. The Sr. Director leads a multi-functional domain that includes Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations. The Sr. Director maintains ultimate accountability for the performance and strategic direction of the full domain and is expected to engage the technology team as a peer, represent these functions at the senior leadership level, and drive continuous improvement across the claims and eligibility ecosystem. The Sr. Director of Claims and Eligibility Operations is required to perform, but not limited to, the following responsibilities:

Strategic Leadership And Domain Ownership

• Own the strategic direction and operational performance of Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations, ensuring each area has clear goals, accountable leadership, and the resources needed to execute

• Serve as the senior decision-making authority for claims and eligibility matters that exceed Director-level resolution capacity

• Define and maintain operational standards, escalation frameworks, and performance benchmarks across all functional areas

• Represent Claims and Eligibility Operations in senior leadership discussions, cross-functional initiatives, and client-facing engagements, including conversations where full claims cost and adjudication transparency is expected by the client

• Partner with the VP of Operations and Sr. Director, Enterprise Operations on org-wide strategy and platform priorities

• Identify and pursue opportunities for automation, AI-assisted workflows, and process improvement across claims and eligibility operations

• Own the development and maintenance of operational dashboards and KPI frameworks across all functional areas, ensuring decisions are data-driven and leadership has consistent visibility into claims accuracy, eligibility performance, QA outcomes, and key operational metrics on a regular reporting cadence

• Operate as an enterprise leader, not just a functional one -- proactively identifying cross-functional risks and contributing to company-wide priorities beyond the claims and eligibility domain

Claims Adjudication Oversight

• Provide senior oversight of the claims adjudication function, ensuring accuracy, timeliness, and compliance with client contractual obligations and regulatory requirements

• Own accountability for adjudication quality metrics and continuous improvement plans, driving measurable gains in claims accuracy and processing performance

• Set the standard for benefit design accuracy and hold the Director of Claims Processing accountable for configuration quality across all client populations

• Drive the adjudication platform agenda with the technology team, setting priorities for enhancements and holding technical partners accountable to production stability standards

• Ensure claims operations are audit-ready and compliant with ERISA, state PBM transparency laws, and applicable regulatory standards, including pass-through pricing validation and ingredient cost accuracy

• Ensure claims adjudication operations maintain compliance with current NCPDP standards and are positioned to support ongoing standard transitions as they are adopted across the industry, including D.0 to F6

• Own the claims QA and testing framework, ensuring systematic validation of adjudication accuracy, benefit configuration, and system changes before and after deployment

Eligibility Operations Oversight

• Provide senior oversight of the eligibility function through the Director of Eligibility Operations, maintaining ultimate accountability for eligibility data integrity, SLA performance, and roadmap execution

• Own the integrity of eligibility data as it flows into downstream adjudication, establishing validation standards and accountability frameworks rather than managing configurations directly

• Own senior escalation authority for eligibility issues that require cross-functional resolution or executive visibility

• Oversee the eligibility product roadmap at a strategic level, ensuring enhancements are prioritized in alignment with operational and client needs

Platform And Technology Partnership

• Serve as the senior operational liaison to the technology team on platform issues, enhancement requests, deployment readiness, and change control processes for both claims and eligibility systems

• Ensure all functional areas are represented in platform governance discussions and that operational requirements are clearly communicated to the technology team prior to deployment

• Own operational readiness across all functional areas for all platform changes, setting standards for deployment governance and holding each area accountable to readiness requirements

• Own accountability for ensuring platform changes are deployed with zero disruption to claims or eligibility processing continuity, with robust change management and contingency planning in place

• Possess sufficient technical fluency in SQL and cloud data platforms to evaluate analytical work, interpret data findings, and engage the technology team with credibility

Cross-Functional Leadership And Client Support

• Collaborate cross-functionally to ensure claims and eligibility accuracy supports downstream operations and client outcomes, and represent the function in finalist presentations and strategic client conversations as needed

• Collaborate with the Compliance and Audit function to ensure operational QA findings are reflected in audit planning and that the two functions remain clearly delineated in scope and accountability

Team Leadership And Development

• Provide strategic direction and senior oversight to the Director of Claims Processing and the Director of Eligibility Operations, each of whom is responsible for day-to-day operations and personnel management within their respective functional area

• Establish clear standards, escalation paths, and operating frameworks that enable all functional areas to perform effectively under their respective Director's leadership

• Own hiring decisions, performance standards, and talent development strategy across all functional areas in partnership with each Director

• Abides by all HIPAA obligations related to Protected Health Information (PHI), reports any discovered violations to the Compliance Officer and/or Human Resources, and completes all required HIPAA training offered by the company

• Flexibility to understand, appreciate, and embrace that the job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice

Required Skills And Competencies

• Deep knowledge of PBM claims adjudication operations within a transparent or pass-through model, including ingredient cost pass-through pricing, dispensing fee structures, accumulator management, benefit design, and claims accuracy standards

• Expert-level understanding of claims adjudication logic, including claim edit sequences, formulary and clinical edit interaction, plan design rule configuration, and the ability to identify and resolve systematic adjudication issues at the engine level

• Demonstrated understanding of formulary management within the adjudication engine, including tier logic, step therapy, quantity limit enforcement, and prior authorization integration at the point of adjudication

• Comprehensive knowledge of NCPDP adjudication transaction formats, including D.0 and F6, with experience supporting standard transitions in a production claims environment

• Deep working knowledge of NCPDP reject code management and adjudication logic, Coordination of Benefits (COB) standards for primary and secondary payer scenarios, and the NCPDP Data Dictionary including segment and field-level transaction requirements and billing and reversal transaction flows

• Expert understanding of eligibility operations including EDI standards (X12 834, 270/271), member enrollment workflows, and the downstream impact of eligibility data on claims adjudication outcomes

• Demonstrated experience leading claims adjudication, quality assurance, and eligibility functions at a senior level within a transparent or pass-through PBM, health plan, or closely related healthcare environment serving ERISA-qualified self-funded plans

• Experience designing or overseeing claims QA programs, including testing protocols, sampling methodologies, and adjudication accuracy validation

• Demonstrated understanding of how transparent PBM pricing models shape adjudication accuracy standards and client reporting obligations

• Strong technical orientation with working proficiency in SQL and familiarity with cloud data platforms such as Snowflake, AWS, or Azure

• Proven ability to engage the technology team as a peer, translating operational requirements into platform specifications and holding technical partners accountable to delivery timelines

• Experience managing operational continuity through technology implementations or significant system changes

• Demonstrated ability to lead through two or more Director-level reports, setting strategic direction while holding each accountable for their functional area's performance

• Excellent written and verbal communication skills with the ability to engage technical and non-technical stakeholders, including client representatives and executive leadership

• High integrity, sound judgment, and demonstrated discretion in handling PHI/PII and sensitive operational matters

• Thrives in a growth-stage environment, bringing structure and clarity where processes are still being built and demonstrating the ability to scale with the organization

Supervisory Responsibility

The Sr. Director of Claims and Eligibility Operations maintains ultimate accountability for the performance, quality, and strategic direction of all functions within the domain. Director-level leaders within the domain are responsible for day-to-day operations and personnel management within their respective functional areas. The Sr. Director partners with each Director on hiring, performance management, and team development and carries senior oversight of all staff within the domain.

Position Type And Expected Hours Of Work

• This is a full-time, salaried position.

• Some flexibility in hours is allowed, but the employee must be available during the core work hours of 8:00 AM to 5:00 PM CT. We cover clients from the West to the East Coast; work times must be adjusted to cover meetings in all zones. Ability to work extended hours, weekends, and holidays under industry demands.

Travel

-Up to 20% for client engagements, vendor reviews, and leadership meetings

Qualifications And Education Requirements

• Bachelor's degree required (Healthcare Administration, Business, Information Systems, or related field)

•10 or more years of progressive experience in PBM claims operations, eligibility management, or closely related healthcare operations leadership

• Demonstrated experience in a transparent or pass-through PBM environment serving ERISA-qualified self-funded plans

• Working knowledge of ERISA fiduciary obligations, self-funded plan administration, and associated regulatory requirements relevant to pharmacy benefit management

• Demonstrated experience owning or providing senior leadership over claims adjudication, quality assurance, and eligibility functions simultaneously, or at a comparable level of operational complexity

• Proven track record of leading Director-level teams and driving measurable operational improvement across multiple functions

• Experience building or overseeing a claims QA function within a PBM, health plan, or closely related healthcare environment

• Experience managing operational continuity through technology implementations or significant system changes

Preferred Qualifications

• Familiarity with comparable claims adjudication and eligibility management platforms

• Background in product ownership, roadmap management, or business systems analysis

• Experience with operational ticketing and workflow management systems such as Jira, Zendesk, or Azure DevOps

• URAC, NCQA, or SOC comparable operational compliance experience

What We Have to Offer

Our benefits package is designed to keep our employees happy - physically, mentally and financially

• Medical, Dental and Vision insurance

• Disability and Life insurance

• Employee Assistance Program

• Remote work options

• Generous Paid-Time Off

• Annual Reviews and Development Plans

• Retirement Plan with company match immediately 100% vested.

Liviniti, LLC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, Liviniti, LLC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Liviniti, LLC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Liviniti, LLC employees to perform their job duties may result in discipline up to and including discharge. EOE M/F/D/V

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